Nursing Elites

1. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

• A. Monitor appetite and observe intake during meals.
• B. Maintain safety in the client's environment.
• C. Provide ongoing, supportive contact.
• D. Encourage participation in activities.

Correct answer: B

Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.

2. What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?

• A. Have the staff escort the client to his room.
• B. Tell the client that his behavior will be recorded in his record.
• C. Redirect the client by asking him to engage in a game with peers.
• D. Review the medication record for an antipsychotic drug.

Correct answer: C

Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.

3. The parents of a nuclear family attending a support group for parents of adolescents are being assessed by the nurse. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?

• A. Loss of independence.
• B. Increased self-understanding.
• C. Isolation from society.
• D. Development of intimate relationships.

Correct answer: B

Rationale: The correct answer is B: Increased self-understanding. According to Erikson's psychosocial development theory, middle adulthood is characterized by generativity, self-reflection, understanding, and acceptance. Middle-aged adults focus on guiding the next generation and finding meaning in their lives. Choices A and C are incorrect because loss of independence and isolation from society are maladaptive behaviors in middle adulthood. While developing and maintaining intimate relationships is important throughout life, the initial development of intimate relationships typically occurs during young adulthood, not middle adulthood.

4. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

5. A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?

• A. Ensure the client is not left alone.
• B. Document the content of the hallucinations.
• C. Administer PRN antipsychotic medication.
• D. Encourage the client to ignore the voices.

Correct answer: A

Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.

Similar Questions